Provider Demographics
NPI:1790397016
Name:PHILLIP'N ELIZABETH CLINICAL STAFFING
Entity Type:Organization
Organization Name:PHILLIP'N ELIZABETH CLINICAL STAFFING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:FONGOD
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:614-314-5416
Mailing Address - Street 1:6455 E LIVINGSTON AVE
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-3589
Mailing Address - Country:US
Mailing Address - Phone:614-314-5416
Mailing Address - Fax:614-861-8842
Practice Address - Street 1:4134 LINDEN AVE STE 306
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45432-3035
Practice Address - Country:US
Practice Address - Phone:614-314-5416
Practice Address - Fax:614-861-8842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service